Failure to Protect Resident from Neglect Following Fall and Inadequate Staff Response
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow proper procedures after the resident experienced a fall. The resident, who had diagnoses including high blood pressure, dementia, and impulse disorder, was admitted to the facility and later complained of increased hip pain. An X-ray revealed an acute displaced fracture of the left proximal femur. Investigation revealed that the fall was not documented in the clinical record, and there was no notification or documentation of the incident. Staff interviews and witness statements indicated that after the resident fell out of bed, an LPN responded but did not assess the resident appropriately and instead forcefully placed the resident back onto the bed without proper evaluation or assistance, then left the room without further care or documentation. The incident was not reported or documented as required by facility policy, and the staff involved did not follow established protocols for post-fall assessment and notification. The Director of Nursing was unaware of the fall until after the injury was discovered, and only learned of the incident through staff interviews during the subsequent investigation. The lack of immediate assessment, failure to notify appropriate personnel, and absence of documentation contributed to the facility's failure to protect the resident from neglect.